condoms

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it. The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters. While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app. Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking. Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication. Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated. Should.

And yet, communication and negotiation are not always straightforward. The result is risky behaviour.

The social determinants of health influence risk-taking. Poverty, for example, is associated with increased risk-taking. In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods. Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Most STIs show no symptoms. To be blunt, if you have had unprotected sexual activity, you need to be tested. But you will not necessarily get an HIV test for example, unless you specifically ask for it. That means you have to actually disclose your unsafe sexual practices. Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body. The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests. But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for (HPV) or a screening test for herpes. You have to show your bump or sore to a doctor. You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex. One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection. If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex. (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com . “Plenty of syph” received a lot of attention, much of it negative. The site has since been revised. But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities. Moreover, the assumption is that “sex” means penis in vagina intercourse. Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic. Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

no unprotected sex

abstinence

mutual monogamy

condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals. In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers. So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured. This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion touched on seniors and safer sex. The statistics for seniors are becoming alarming. Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64. Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults. Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs. They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship. They may also be learning the dating game the “hard” way. A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV. Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria. Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

In 2013, I wrote a blog on new provincial and federal cervical screening guidelines (https://springtalkssex.wordpress.com/2015/01/08/confused-about-pap-tests-july-2-2013/) partly because women’s health advocates were worried that these updated policies were putting women at risk in order to save money. There was no risk, in my opinion, in delaying the initial Pap or from the longer interlude between screening tests. But there certainly was a risk: not informing women of the difference between cervical screening and Sexually Transmitted Infection (STI) testing.

Because most Human Papilloma Virus (HPV) infections resolve on their own, research indicated that earlier and annual testing did not decrease sickness or death from cervical cancer. Even high-risk HPV infections that cause cellular changes on the cervix tend to resolve on their own without treatment. Cervical cancer develops when there is persistent infection with a high-risk type of HPV in the presence of co-factors like a suppressed immune system. Pap testing (and/or HPV testing) indicate when treatment is necessary to prevent its development.

When Cancer Care Ontario (CCO) published fact sheets to inform the public about the new guidelines, I contacted them to point out that they also needed to provide information about the importance of STI testing. It was obvious to me at the time that there would be repercussions.

I had been selling the annual Pap as part of sexual health education classes for years. Suddenly, young women (including trans men with a cervix) were being told they didn’t have to start till they were 21 (Ontario) or 25 (federally); and they didn’t need to have a Pap every year. So, of course, many stopped having internal exams until they were told they had to.

Young women, in my experience, especially those whose annual Pap test coincided with – and in some cases were dependent on – their birth control pill renewal, had no idea what was going on during their internal exam. Despite the efforts of sexual health educators in the classroom to distinguish between the Pap test (checking for abnormal cells on the cervix) and STI screening (swabbing the cervix and inside of the vagina) when they arrived at clinic for their exam, counsellors had to take the time to explain it again. It is not clear if Physical Education teachers and family physicians today consider it important to educate about this important difference.

So what’s the big deal?

The importance of the distinction becomes clear when we look at the statistics. According to the lead researcher of a recently published article on this issue (see below), over the past 10 years, chlamydia and gonorrhea rates in Canadians rose by 72 and 53 per cent, respectively, especially for chlamydia. The highest number of cases of chlamydia are diagnosed in young people between the ages of 15 – 24. The increase in diagnoses was in part due to Public Health Units encouraging an increase in testing in the early 2000s. The urine (NAAT) test (v-e-e-ry appealing to men) also brought in more young people for testing. One of the suspected behavioural reasons for the increased number of cases was less condom use among older adolescents and young adults who made the switch from condoms to hormonal contraception without being tested first.

Untreated chlamydia, which is commonly asymptomatic, can do serious damage to the Fallopian tubes. Moreover, untreated STIs which provoke an increase in white blood cells at the site of the infection, make it easier for HIV to enter the bloodstream.

Here come the chickens

St. Michael’s Hospital in Toronto raised the alarm about a decrease in testing in their recent study (http://www.sciencedaily.com/releases/2015/10/151015144701.htm). The lead researcher said, “…we found that women weren’t visiting family physicians as often for Pap tests, causing a drop in STI screening as well. Female patients were also less likely to be screened for syphilis, hepatitis C and HIV under the new guidelines…”

When I contacted Cancer Care Ontario to complain about the lack of information on the importance of ongoing STI testing, the woman I spoke to thought it would be confusing to try to explain the difference between the various types of testing. Prior to writing this blog, I re-visited the CCO web-site looking for what I hoped would be updated literature. There is still no mention at all of STI testing.

The takeaway for readers with a cervix is this: if you have had unprotected sexual activity, whether you have symptoms or not, see your health care provider even though it is not time for your Pap test. They will look at your genitals; they will test you for chlamydia and gonorrhea and any blood-borne infections you may have been exposed to.

As for me, I guess it’s time to contact CCO medical directors encouraging them to read the St. Michael’s study. I wonder if they still think it’s too much for women’s brains to handle.

Recently I was asked to do an interview for CBC French television on sexual activity during the Pan Am games. Perhaps they thought I would be prescient about any increase. The reporter was also planning to interview someone from a local sex workers’ support and advocacy group. As we were chatting, I thought back to a blog I had written about the proposed law (https://springtalkssex.wordpress.com/2015/01/08/sex-work-march-3-2014/) and how its implementation might change as the games approached.

“Let the games begin” is the slogan of this year’s Toronto condom campaign, coinciding with Pan Am activities. Toronto Public Health recognizes, of course, that there will be fun with those games. People like to party and they want to remind both Torontonians and visitors to party safely. But the games also mean increased job opportunities, even for me and the two bands I play with. So one might think the same would hold true for sex workers.

Because if we start from the premise that sex work is work, then their working conditions need to be taken into consideration. Unfortunately, sex work has not officially been deemed as such because prostitution has not been decriminalized.

So this is where it becomes tricky. The new law is no better – and even somewhat worse – than the old one. The Supreme Court ruling was meant to protect sex workers; but they are, in fact more vulnerable than ever. In terms of implementation, the Ontario Premier said, “The position we’re taking is that we’ll follow the rule of law, the law that’s in place… but I have asked the attorney general to look at the potential of unconstitutionality and to give us some options in terms of what we might do going forward.”

One would have to be privy to the word on the street to find out if, indeed, Toronto police are currently implementing the new law; and whether or not they are planning sweeps to coincide with the games. This is a real concern. I remember the sweeps that took my clients off the streets when I was doing the condom distribution rounds for Public Health. Some of them would go through the jails’ revolving doors. Eventually they would all drift back to the same turf.

“Police in Vancouver made some efforts to curb street prostitution and petty crime before the Winter Games two years earlier. The executive director of Maggie’s, a Toronto organization run by and for sex workers, says fears over potential trafficking during sports competitions are typically overblown and sometimes serve as excuses to round up local and foreign sex workers.”

A study (http://www.biomedcentral.com/1471-2458/12/763) examining the impact of the Vancouver Olympics suggests there was no significant influx of sex workers or reports of a spike in trafficking there. There was less demand for their services, possibly due to the difficulty in meeting clients.

Regarding the trafficking issue, Butterfly, (http://wearestrut.org/our-work/the-migrant-sex-worker-gathering/) an organization supporting migrant sex workers, insists that racialized and migrant sex workers are especially vulnerable because of their immigration status, language barriers and race. They blame the federal government’s change of immigration policy in recent years, which restricts some of the migrant work that can be done legally in Canada. The end result is they sometimes look for work underground – like sex work. The organization insists that one should not assume that all migrant sex workers are being trafficked.

So will there be increased sexual activity during the games? Most likely, but it may not be increased paid activity. Some visitors may hook up with people they meet at events, clubs and bars; and some may attempt to avoid being charged for purchasing sexual services in the street by hastily negotiating their hook-up, putting sex workers at increased risk.

In the meantime, the relationship between sex workers and the local police will certainly be put to the test. Let the games begin.

Let’s start with cunnilingus (a very good place to start, some would say). There have always been negative attitudes about oral sex on women because of repugnance towards female genitals. Apparently, we smell, we’re dirty; and we don’t look the way we should. Feminine hygiene products included Lysol in the early days of making women feel bad about their genital scent. Female genital cosmetic cutting and anal bleaching are the contemporary equivalents. However, it would appear that some people have gotten over that prejudice, because in films and on TV, men are going down on women in droves, not to mention woman on woman action as well. However, I’ve met many young men who gave their female partners oral sex, but didn’t want their male friends to know; it was considered unmanly.

Interestingly, there are also prejudices against oral sex on a man. I worked with young women who said they could never kiss their baby after they had put their mouth on a man’s penis.

Oral sex has been on the menu for a long time, soon to be replaced in popularity, at least according to the media, by anal sex, even though statistics do not bear this out. We have some statistics regarding oral sex for adolescents. They mirror age-related statistics on vaginal intercourse—about half of the teen population are having vaginal and oral sex by age 17. The “epidemic” of teen oral sex never did materialize since the first hysterical media stories more than 15 years ago. Unfortunately, we can only guess at who’s giving and who’s getting. As sexualityandu.ca suggests, “It is sometimes assumed that with respect to teen oral sex there is a gender discrepancy in which females are more likely to be giving (fellatio) rather than receiving (cunnilingus) oral sex from their male partners.”

It is a fair assumption that for young women, oral sex on a young male partner is one way of preventing pregnancy and postponing vaginal intercourse. A lot of ink has been spilled over whether young women find it enjoyable and/or empowering to give oral sex to a male partner. I’d like to see a good study on that.

These days, adults are seeing oral sex in a different light: will it give me cancer?

Oddly, there has not been much discussion about a risk that is much more common: genital herpes. A person with a history of cold sores (even when no sore is present) can pass herpes simplex virus 1 (HSV-1) to a partner’s genitals. Part of my health promotion message has been that is it a courtesy to tell a person you have a history of cold sores, offering to cover your partner’s genitals before oral sex. Part of someone’s decision might include the fact that HSV-1 tends to recur less frequently than HSV- 2 on the genitals and tends to be less painful. I was recently called “sexist” for suggesting that men would tend to dismiss such protection in a nanosecond. A propos, I have never met a woman, no matter with whom she had sex, who used an oral latex barrier to receive oral sex.

Men having unprotected oral sex with multiple male partners are at risk for syphilis. My clinic experience tells me that, like heterosexuals and women who have sex with women, they are not likely to use protection for oral sex. They need to be tested more frequently, since untreated syphilis puts them at higher risk for HIV.

But Iet’s get back to Michael Douglas and throat cancer.

I have been following the HPV and oral sex story for several years. Although there has been speculation that the increase in HPV-related mouth and throat cancers (which is on the rise) may be related to the increase in oral sex in earlier decades, there has been no definitive proof. The non-HPV-related head and neck cancers are related to alcohol and tobacco abuse.

HPV is only a problem when it is persistent. Most people clear the virus in the first or second year after infection.

This information leaves people with some decisions to make.

The Public Health message, which I consider unrealistic, has always been to use a latex barrier for oral sex. People don’t, and then they feel guilty.

Unfortunately, there are no screening tests for HPV in Canada; i.e., although a Pap test may indicate the presence of HPV, it does not test for it. Genital warts are generally diagnosed on visual examination. The overwhelming majority of adults will have been infected with some strain or other of HPV in their lifetime. Most of them will have gotten rid of it.

So here are your homework questions:

If you always use condoms with a male partner for intercourse (or at least, until you’ve both been tested), does that also apply for oral sex?

If someone tells you they have a history of cold sores, are you going to politely decline oral sex, use a latex barrier or say, just do it?

Will fear of cancer mean you’re going to cover your next lover’s genitals with latex before you give them oral sex, even though the numbers of these cancers are still relatively low?

If you’ve ever had a bout of genital warts, do you need to tell a partner before they put their lips on yours (the other ones) even though genital warts are more a nuisance than a danger?

Bottom line, we need to decide on the level of risk we are willing to take.

Actually, it seems to be in their hands. Handheld devices give teenagers access to sexual images—including unsolicited images of their peers—as well as anything they could possibly want to know about sex, both positive and negative. The unsolicited photos are an obvious negative, but some of the positives are that they can find a clinic, text a health agency for information, even let a partner know anonymously that they have an STI and need to get tested. With the increase in information from all sources, there have been some real advances in sexual health for adolescents and young adults; but there are still serious problems. So what are they really up to? Media messages mislead adults about adolescent sexual activity, giving the impression that they are having sex at increasingly younger ages. Federal and provincial health surveys seem to tell a different story. In 1996, 32 per cent of 15- to 17-year-olds reported that they had had (vaginal) intercourse; in 2003 and 2009, it was 30 per cent. Moreover, for 18- to 19-year-olds, fewer are reporting having had intercourse than previously. In 1996, it was 70 per cent; in 2009, it dropped to 68 per cent. Condom use is also increasing. Sixty-eight per cent of sexually active Canadians aged 15 to 24 reported using condoms in 2009-2010, compared to 62 per cent in 2003. However, older teenagers are less consistent in their condom use: for 18- to 19-year-olds (with one partner), 72.7 per cent used condoms the last time they had sex as compared to 81.2 per cent of 15- to 17-year-olds. The likely reason for the heterosexual teenagers is that the young women are on the Pill. Like deciding to postpone sex, condom use requires negotiation. In certain social groups, condoms are de rigueur. When I worked in a sexual health clinic, I noticed that there were some young people who were more sophisticated than many adults I know in terms of their ability to make sexual decisions. For example, young men were coming in with their female partners for testing, a great new twist on a date. The rates for adolescent pregnancy have plunged dramatically since the 1970s, with the increase in comprehensive sexual health education and access to birth control and safe abortion as back-up. The remaining pockets of adolescent pregnancy are still to be addressed by increased access to the basics: adequate food, shelter and safety, including sexual safety. Another positive: adolescents are coming out to themselves at younger and younger ages about their sexual orientation and/or gender issues. So we’re getting some things right by changing the discourse at home and school to ensure that they hear lesbian/gay/bisexual/trans (LGBT) positive messages. But we still need to up our game. The older adolescents who are no longer using condoms may not be getting pregnant, but they are getting STIs in record numbers. The number of cases of Chlamydia for 15- to 24-year-olds, for example, continues to rise. This is in part due to more, and better, testing. (Urine tests for males as opposed to swabs make it a lot easier to convince them to go.) As mentioned, heterosexual teenage girls and young women in longer term relationships (three weeks or more!) are starting to use hormonal contraception, such as the Pill, as their method of birth control. But they tend to start the Pill before they get tested for STIs. As soon as they go on the Pill, they stop using condoms. They may be unaware that they were already infected with an STI from a previous partner, or they may get infected by their steady, loving partner, who was himself unaware that he was infected. To my mind, the most dramatic barrier to adolescent sexual health, as I reported in an earlier blog is the persistence of acquaintance rape and the apparent lack of empathy for its victims. Right alongside this phenomenon is intimate partner violence—emotional, physical and sexual abuse—that often starts in adolescence and persists into young adulthood, with the overwhelming majority of victims of intimate partner violence being female. While I fully acknowledge that each one of these problems has many factors, including high-risk behaviors linked to economic and social disadvantages, education remains a key factor. With increased education and access to services, we will be able to keep pushing down the stats on STIs and teenage pregnancy; but it will take some phone smarts to turn those handheld devices to our advantage. Agents for change will have to learn to blast positive messages to each and every one of them. I propose a new Twitter tag: #goodteensex.

Everyone knows someone who has tried online dating. Was it fabulous for them? Perhaps from the outside looking in. From inside, it can be rather dingy and depressing. Speaking personally, there may be other 65-year-old women who are having a blast. I am not.

It’s been a year since my last online dating experience. A promising (somewhat younger) man who was clearly turned on to me, disappeared in a puff of smoke after a very brief affair.

Here’s how it works. You begin with a profile, trying to make yourself stand out from the crowd—cheerful, attractive and interesting. You are encouraged to post pictures of yourself doing fun stuff. In my age bracket, there are lots of photos of men with their cars, their dogs, their children and their grandchildren. Of course, when you begin to read through the profiles of the potentials whose photos are appealing (in my case, no dogs or cars), they seem dismally similar. Comfortable in a tux or jeans. Loves to cuddle by the fire drinking wine (does everyone have a functioning fireplace?). Works out every day, cycles, skis, loves to travel…

Then, if you finally find someone literate and interesting, you work up the courage to send a message and… Well, like my last go round, it may result in a rushed first coffee date with enthusiastic follow-up. Or, you get nothing. If you’re lucky, you get a civil “thanks, but no thanks.” What feels worse is a flurry of messaging back and forth, and then nothing. I am told that the lack of etiquette is the etiquette of online dating.

Sometimes you get a date—or a few with the same person. Sometimes you have a short-term or even longer-term relationship; and then it’s back to online dating, unless you meet a real, honest-to-goodness long-term partner, which for some is the ultimate, seemingly unattainable end game.

So what does all this have to do with sexual health?

Well, for one thing, it can be very hard on one’s self-esteem. Unless you have a very thick skin, being ignored—or worse, rejected—can be hard to take. Some people check their sites obsessively to see who has looked at their profile, or to scroll through potentials; others casually take a peek from time to time. Lately, I’ve been weaning myself off, only checking in when there is some action (So and so wants to meet you! You’ve got a new message!).

The other issue is safety. I don’t mean avoiding axe murderers or con men/women, but sexual safety. If you do meet someone, and go the “first base, second base” route ending up in bed, there is the tricky question of protection. Being a sexual health educator, I am more aware than most of the risks of non-condom use. Having preached communication for my entire career, I can finally discuss both condom use and testing with someone quite easily. I can also weigh the risks of activities like oral sex without a condom. I doubt that this is the case for most women who are relatively new to the dating game.

As I explained in my article on older women and sexuality, while it is hard enough for younger people to negotiate safer sex because of embarrassment or an inability to assert themselves, an older woman whose long-term relationship ended because of separation or death, has not had to deal with STI prevention for years, if ever. One cannot make the assumption that this previous long-term relationship was necessarily mutually monogamous. That, and a newly discovered zest for hanky-panky have resulted in an increase in STIs for baby boomers.

One should not entirely dismiss the potential for sexual assault or emotional abuse. I shocked a friend once by putting myself in a risky situation. Google can give you some sense of a person after you meet on a site and you eventually exchange full names and e-mail addresses. I recently visited a potential’s Facebook page and discovered he was a right-wing racist. That certainly killed the mood. Of course, a really good con man or woman can create a fictional bio with relative ease. There are many cases of people being bilked of their pensions by imaginative suitors. It can be hard to find a reasonable balance between vigilance—watching for red flags—and relaxing into what seems like a trustworthy relationship.

It isn’t easy to meet a potential partner offline—as in real life. You have to ascertain that the person is interested at some level and then figure out if they are attached. Attempting to find that out can be embarrassing and tip your hand. And while you may want someone to “fix you up” with their dentist, for others it’s the kiss of death.

Yes, it sounds like a game and I suppose, in some ways it is. But games are supposed to be fun. The online dating game: not so much. The bottom line is that you already have a life. A partner will not create your life, although they may enrich what you have. So, approach your keyboard with caution and a sense of irony. Getting lucky may end up being no more than maintaining your status quo.